By Counterforce Health Team in Orladeyo (berotralstat) —

Get Orladeyo (berotralstat) Covered by Blue Cross Blue Shield in Virginia: Forms, Appeals, and Step-by-Step Guide

Answer Box: Getting Orladeyo Covered in Virginia

To get Orladeyo (berotralstat) covered by Blue Cross Blue Shield in Virginia, you need prior authorization from an HAE specialist. Start by having your allergist or immunologist submit a PA request through Anthem's provider portal with documented C1-INH testing, prior therapy failures, and clinical justification. If denied, you have 180 days to appeal internally, then can request external review through Virginia's State Corporation Commission within 120 days. Success rates improve significantly with comprehensive specialist documentation and evidence-based appeals.

First step today: Contact your HAE specialist to initiate the prior authorization process.

Table of Contents

  1. Verify Your Plan and Find the Right Forms
  2. Prior Authorization Requirements and Forms
  3. Submission Portals and Electronic Systems
  4. Fax and Mail Submission Details
  5. Specialty Pharmacy Network and Transfer Process
  6. Support Lines and Contact Numbers
  7. Virginia State Appeals and External Review
  8. Common Denial Reasons and How to Fix Them
  9. Medical Necessity Letter Essentials
  10. Costs and Patient Assistance Options
  11. FAQ

Verify Your Plan and Find the Right Forms

Before starting your Orladeyo coverage request, confirm you have Anthem Blue Cross Blue Shield Virginia coverage. Different Blue Cross Blue Shield plans across the country have varying requirements, so it's crucial to work with Virginia-specific policies.

Coverage at a Glance

Requirement Details Where to Find It
Prior Authorization Required for all members Anthem Provider Portal
Formulary Status Specialty tier, non-preferred Member portal or call member services
Step Therapy May be required PA determination process
Age Restriction ≥12 years old FDA labeling requirement
Specialist Requirement HAE specialist (allergist/immunologist) Anthem clinical criteria
C1-INH Testing Required for diagnosis confirmation Clinical documentation

Prior Authorization Requirements and Forms

Anthem Blue Cross Blue Shield Virginia requires prior authorization for Orladeyo as of 2024. The process has been updated multiple times throughout the year, so always verify you're using current requirements.

Required Documentation

Your HAE specialist must provide:

  • Confirmed HAE diagnosis with genetic testing or C1-INH lab results (low C4 levels, low C1-INH antigenic or functional levels)
  • Prior therapy documentation showing failure, intolerance, or contraindications to preferred alternatives like Takhzyro (lanadelumab), Haegarda, or Cinryze
  • Attack frequency and severity logs demonstrating need for prophylaxis
  • Clinical justification for oral therapy over injectable options
  • Dosing rationale aligned with FDA labeling
Clinician Corner: The medical necessity letter should explicitly state your expertise in HAE management and reference current treatment guidelines. Include specific dates of prior therapies, documented adverse events or lack of efficacy, and patient-specific factors favoring oral prophylaxis.

Submission Portals and Electronic Systems

Primary Submission Methods

  1. Anthem Provider Portal - Preferred method for electronic PA requests
    • Requires provider registration and login
    • Allows document uploads and status tracking
    • Provides real-time updates on authorization status
  2. Availity Essentials - Alternative electronic submission platform
    • Integrated with many EMR systems
    • Supports bulk submissions for practices

Required Provider Information

  • NPI number
  • Practice address and contact information
  • Patient demographics and insurance details
  • Clinical documentation and supporting labs

Fax and Mail Submission Details

For providers who cannot access electronic portals, Anthem accepts PA requests via fax. Always include a cover sheet with:

  • Patient name and member ID
  • Provider name and NPI
  • Medication name (Orladeyo/berotralstat)
  • Urgency level (standard or expedited)
  • Number of pages being transmitted
Tip: Keep fax confirmation receipts and follow up within 48-72 hours to ensure receipt, especially for time-sensitive requests.

Specialty Pharmacy Network and Transfer Process

Orladeyo is typically dispensed through specialty pharmacies in Anthem's network. Common options include:

Network Specialty Pharmacies

  • CVS Specialty Pharmacy
    • Phone: (800) 237-2767
    • Fax: (800) 323-2445
  • Accredo Specialty Pharmacy
    • Integrated with Express Scripts network
    • Provides patient education and adherence support

Transfer Process

  1. Contact your preferred specialty pharmacy from Anthem's network
  2. Provide insurance and prescription information
  3. Confirm prior authorization status before transfer
  4. Request pharmacy-to-pharmacy transfer if switching from another specialty pharmacy
  5. Verify shipping and delivery arrangements

The specialty pharmacy will coordinate with your physician to obtain necessary prescriptions and clinical documentation.

Support Lines and Contact Numbers

For Patients

  • Anthem Member Services: Check your member ID card for the specific number
  • Prior Authorization Status: Available through member portal or phone
  • Specialty Pharmacy Questions: Contact your assigned specialty pharmacy directly

For Providers

  • Provider Services: Available through Anthem's provider portal
  • Prior Authorization Support: Electronic submission preferred
  • Peer-to-Peer Review: Can be requested if initial PA is denied

Virginia State Appeals and External Review

If Anthem denies your Orladeyo request, Virginia offers robust appeal protections through the State Corporation Commission Bureau of Insurance.

Appeals Timeline

Stage Deadline Decision Time Next Step
Internal Appeal 180 days from denial 15-30 days (72 hours if expedited) External review if denied
External Review 120 days from final internal denial 45 days (72 hours if expedited) Binding decision

Virginia External Review Process

Contact Information:

  • Address: State Corporation Commission, Bureau of Insurance – External Review, P.O. Box 1157, Richmond, VA 23218
  • Phone: 1-877-310-6560
  • Email: [email protected]
  • Fax: (804) 371-9915

Required Forms:

  • Form 216-A (External Review Request Form)
  • Form 216-B (if filed by someone other than the patient)

Virginia's external review process has overturned many pharmacy denials, with success rates of 30-40% for well-documented cases. The process is free to patients and provides an independent medical review.

Common Denial Reasons and How to Fix Them

Denial Reason How to Address
"Not medically necessary" Provide detailed attack logs, impact on quality of life, specialist letter
"Step therapy required" Document failures/intolerance to Takhzyro, Haegarda, Cinryze
"Age restriction" Confirm patient is ≥12 years old per FDA labeling
"Insufficient diagnosis" Submit C1-INH testing, genetic results, family history
"Non-formulary medication" Request formulary exception with clinical justification
"Concurrent prophylaxis" Clarify that other HAE prophylaxis will be discontinued

Medical Necessity Letter Essentials

A strong medical necessity letter should include:

Clinical Documentation Checklist

  • HAE diagnosis confirmation with specific lab values or genetic testing results
  • Attack frequency and severity over the past 6-12 months
  • Prior prophylaxis attempts with specific medications, durations, and outcomes
  • Contraindications or intolerance to preferred alternatives
  • Patient-specific factors favoring oral therapy (injection phobia, lifestyle, adherence)
  • Treatment goals and expected outcomes with Orladeyo
  • Monitoring plan and follow-up schedule

Supporting Evidence

Reference current treatment guidelines and FDA labeling. The World Allergy Organization guidelines support individualized prophylaxis selection based on attack burden, patient preference, and medication access.

From our advocates: We've seen the strongest appeals combine detailed attack logs with specific documentation of why injectable prophylaxis isn't suitable for the individual patient. One successful case involved a healthcare worker whose schedule made regular injections impractical, leading to poor adherence with Takhzyro. The oral convenience of Orladeyo was key to the approval.

Costs and Patient Assistance Options

Orladeyo's wholesale acquisition cost is approximately $44,484 per 28-day supply as of 2025. However, multiple assistance programs can significantly reduce patient costs:

Financial Assistance Programs

  • BioCryst Patient Assistance Program - Income-based assistance for eligible patients
  • Copay Support Programs - May reduce out-of-pocket costs for insured patients
  • Foundation Grants - Various rare disease foundations offer medication assistance

Contact BioCryst Pharmaceuticals directly or visit their website for current program details and eligibility requirements.

FAQ

How long does Anthem's prior authorization process take in Virginia? Standard PA decisions are typically made within 15 business days. Expedited requests (when delay could harm health) are decided within 72 hours.

What if Orladeyo is non-formulary on my plan? You can request a formulary exception by demonstrating medical necessity and showing that preferred alternatives are inappropriate or ineffective for your situation.

Can I request an expedited appeal if my request is denied? Yes, if your physician certifies that waiting for a standard appeal could seriously jeopardize your health or ability to function.

Does step therapy apply if I've tried other HAE medications outside Virginia? Yes, documented trials from other states or providers count toward step therapy requirements, as long as you have proper medical records.

What specialist qualifications does Anthem require? Orladeyo must be prescribed by a physician with expertise in HAE, typically an allergist, immunologist, or hematologist familiar with hereditary angioedema management.

How often do I need to renew prior authorization? Most authorizations are valid for 12 months and require renewal with documentation of continued medical necessity and treatment response.

Counterforce Health helps patients and clinicians navigate complex insurance appeals for specialty medications like Orladeyo. Their platform analyzes denial letters, identifies specific coverage criteria, and generates targeted, evidence-based appeals that address each payer's requirements. By combining clinical expertise with insurance policy knowledge, Counterforce Health has helped many patients access critical treatments through successful appeals.

Whether you're dealing with your first Orladeyo coverage request or appealing a denial, having the right documentation and understanding Anthem's specific requirements in Virginia can make the difference between approval and continued delays. Don't hesitate to use Virginia's external review process if needed – it's designed to provide an independent assessment of medical necessity when insurers and patients disagree.

For additional support with complex appeals or if you need help navigating the process, Counterforce Health offers specialized expertise in turning insurance denials into successful approvals through targeted, evidence-backed appeals.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and is not medical advice. Always consult with your healthcare provider and insurance plan for the most current requirements and coverage details. Insurance policies and procedures may change without notice.

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